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    Pap Smear

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    tenny21092000

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    Pap Smear

    Uploaded by

    tenny21092000
    2 views20 pages

    Original Title

    Pap smear

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    2 views20 pages

    Pap Smear

    Uploaded by

    tenny21092000

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 20

    CASE

    PRESENTATIO
    N
    PRECEPTOR: DR. FIDES ABABON
    IDENTIFYING
    DATA
     Patient Name : S.V
     Age : 45
     Civil status : Married
     Religion : Catholic
     Address : Barangay 9A, Davao City
     Occupation : Home maker
     Informant : Patient
     Reliability : 90%
     Date : Sep 14, 2023
    CHIEF
    COMPLAINT
    Lower back pain
    HISTORY OF  2 weeks PTC, the patient had an onset of
    lower back pain (pain scale 10/10). The

    PRESENT pain was on and off and cramping in


    character. The pain aggregates while
    moving and working. The patient took
    ILLNESS paracetamol 500mg as need for pain which
    gave temporary relief. The patient had
    associated symptom of discomfort in the
    cervix. No consultation was done.
     2 days PTC, the patient still had
    aforementioned signs and symptoms
    associated with running nose and
    productive cough. The suptum was clear
    sticky in consistency. No meds were taken.
    No consultation was done.
     Today due the persistence of the
    symptoms the patient came in for
    consultation
    OBSTETRIC AND GYNECOLOGICAL
    HISTORY

     Menarche:13 years old


     Regular Flow
     3 pads/day
     Coitarche : 33 years old
     (-) Dysmenorrhoea
     OB CODE: G3P3 (3003)
     All three children were deliver via NSVD without complications.
     LMP: First week of September
    PAST MEDICAL HISTORY

     No childhood illness
     The patient has asthma which is controlled.
     UTI at 33 years old, during her first pregnancy.
     IUD insertion (2016) seven years ago.
     No history of hospitalization
     No surgical history noted
     No history of psychiatric illness
    FAMILY  Positive history of Diabetes from
    the maternal side.

    HISTORY  No history of genetically


    transmitted diseases in the
    family
     No history of cancer in the
    family.
    PERSONAL AND SOCIAL HISTORY

     Non smoker and non alcoholic beverage drinker.


     Eats regular filipino diet like chicken, fish, rice, vegetables
     No alternative health practices were followed.
     5 in the family living in a small house.
    REVIEW 

    General: (-) fever, (-) weakness
    Skin: (-) rashes; (-) lesions
    OF  Head: (-) headache, (-) dizziness

    SYSTEMS
     Eyes: (-) redness, (-) blurred
    vision
     Ears: (-) tinnitus, (-) discharge
     Nose: (-) nasal stiffness, (-) nose
    bleeds
     Mouth:(-) bleeding gums, (-) sore
    throat
     Neck: (-) cervical
    lymphadenopathy, (-) pain
     Breast : (-) tenderness, (-) lumps,
    (-) nipple discharge
    REVIEW OF
    SYSTEMS
     Circulatory: (-) angina, (-)
    palpitations.
     Abdomen: (-) nausea, (-) vomiting
     Chest and lungs: (-) cough, (-)
    dyspnea, (-) wheezing.
     Genitourinary: (-) dysuria, (-) urinary
    frequency
     Neurological: (-) seizures, (-) dizziness,
    (-) vertigo
     Endocrine: (-) heat or cold tolerance
    PHYSICAL
    EXAMINATION
     GENERAL:
    The patient was conscious, coherent and cooperative

     VITALS:
    Temp: 36.9° C
    RR: 19 cpm
    PR: 80 bpm
    BP: 120/70 mmHg
    PHYSICAL
    EXAMINATION
     SHEENT:
     Skin: There is no discoloration, rashes or lesions found
     Head: There is normal distribution of hair, no scaliness, lumps or other lesions
    found.
     Eyes: There is no edema of eye, No excessive tearing is found, pink palpebral
    conjuctiva , no nystagmus
     Ears: Normal whispered voice test no discharge, foreign bodies and redness of skin
     Nose: Normal sniff test, no nasal congestion, no sinus found.
     Mouth and throat: No bleeding of gums no oral sores no selling ulceration in
    pharynx
     Neck: No Palpable cervical lymphadenopathy noted
     Breast: no tenderness and no abnormal nipple discharge.
    PHYSICAL
    EXAMINATION
     Chest and lungs:
    Inspection- no subcostal retraction noted
    Palpation- Normal tactile fremitus
    Percussion- Resonant felt equally on both side of lung fields
    Auscultation- Bronchovesicular breath sounds heard in both lung
    fields
     Cardiovascular :
    Inspection- Adynamic precordium
    Palpation- No heaves and thrills
    Auscultation- Distinct s1 and s2 without extra heart sounds and no
    murmurs heard.
     ABDOMEN :
    Inspection: Symmetrical, flat without
    lesions
    Auscultation: Clicks and gurgles are heard.
    PHYSICAL No bruits are heard.
    EXAMINATION Palpation: No masses, not tender.
     EXTREMITIES:
    No edema
    No weak pulses
    Genitalia
     External Genitalia: No masses, no
    lesions, no rashes or lacerations.
     Speculum Exam : Upon
    inspection, the cervix was moist
    and pink in color. Whitish
    discharge over the fornices and
    lateral walls of the vagina.
     Pap smear samples were take
    from the endocervix and vaginal
    walls for examination.
     Due to discomfort in the cervix,
    IUD was removed and gave relief.
    PAP SMEAR
    Results :
    • Predominance of coco bacilli
    consistent with shift of vaginal
    flora
    • Follicular cervicitis
    SALIENT FEATURES IN HISTORY

     23 years old female (G1P0)


     LMP: April 18, 2023; AOG: 19 weeks 0 day; EDC: DECEMBER 4, 2023
     Weight gain in every prenatal visits.
    SALIENT FEATURES IN PE

     There was slight tenderness felt during the Palpation of breast


     Symmetric & slightly globular & not distended, Presence of striae was
    mildly noted during the inspection of abdomen
     On Palpation of abdomen, fundic height was noted to be 10 cm
    FINAL DIAGNOSIS

     Gravida 1 Para 0 Pregnancy Uterine 19 weeks 0 days AOG by LMP, Not


    in labor.
    THANK Presented by,
     43. JOHN MARI VIENNI JOHN

    YOU DOC 
    TENNYSON
    44. JOLAKULA SURESH SADHVI

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